ATI RN
ATI RN Adult Medical Surgical 2023 Questions Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is 3 hr postoperative following a total knee arthroplasty. Which of the following actions should the nurse take to prevent venous thromboembolism?
Correct Answer: A
Rationale:
Correct Answer: A - Encourage the client to perform circumduction of the feet.
Rationale: Circumduction of the feet involves moving the feet in a circular motion, which helps promote blood circulation and prevent stasis in the lower extremities. This movement aids in preventing venous thromboembolism by reducing the risk of blood clots forming in the legs postoperatively. Encouraging this activity is crucial in maintaining vascular health and preventing complications.
Summary of Incorrect
Choices:
B: Keeping the client's knees in a flexed position while in bed may lead to decreased circulation and increase the risk of venous stasis.
C: Massaging the client's legs every 4 hours can dislodge blood clots and increase the risk of embolism.
D: Limiting fluid intake can lead to dehydration, which can increase the risk of clot formation due to thicker blood consistency.
Question 2 of 5
A nurse is planning care for a client who has *Clostridium difficile* gastroenteritis. Which of the following is an appropriate nursing action?
Correct Answer: C
Rationale: The correct answer is C: Obtain a stool specimen with gloves.
Rationale:
1. Clostridium difficile is transmitted through contact with feces, so obtaining a stool specimen with gloves is essential to prevent the spread of infection.
2. Using gloves during specimen collection reduces the risk of contaminating hands and surfaces.
3. It is important to identify the specific pathogen causing the gastroenteritis to determine the appropriate treatment.
Summary of incorrect choices:
A: Placing the client in a protective environment is not necessary for Clostridium difficile gastroenteritis.
B: Cleaning surfaces with chlorhexidine is important for infection control but not the most appropriate action in this scenario.
D: Washing hands with alcohol-based hand rub is important for general infection control but not specific to obtaining a stool specimen.
Overall, choice C is the most relevant and appropriate nursing action in this situation.
Question 3 of 5
A nurse is reviewing the medical record of a client who has acute gout. The nurse should expect an increase in which of the following laboratory results?
Correct Answer: C
Rationale: The correct answer is C: Uric acid. In acute gout, there is an increase in the production or decrease in the excretion of uric acid, leading to elevated levels in the blood. This results in the formation of urate crystals in the joints, causing inflammation and pain.
Choices A, B, and D are unrelated to acute gout. A chronic level (
Choice
A) does not indicate an acute condition. Creatinine kinase (
Choice
B) is an enzyme related to muscle damage, not specific to gout. Immac factor (
Choice
D) is not a relevant marker for acute gout.
Therefore, the correct answer is C as it directly correlates with the pathophysiology of acute gout.
Question 4 of 5
A nurse is caring for a client who is postoperative following a below-the-knee amputation. Which of the following statements made by the client indicates acceptance of their altered body image?
Correct Answer: A
Rationale: The correct answer is A because the statement indicates the client's willingness to connect with someone who has undergone a similar experience, showing acceptance and readiness to learn from others in similar situations. This demonstrates the client's acknowledgment of their altered body image and a proactive approach towards coping with it positively.
Choice B reflects avoidance behavior, not acceptance.
Choice C focuses on the relief of pain rather than acceptance of body image changes.
Choice D suggests resignation rather than acceptance.
Question 5 of 5
A nurse is caring for a client who is 3 hr postoperative following a total knee arthroplasty. Which of the following actions should the nurse take to prevent venous thromboembolism?
Correct Answer: A
Rationale:
Correct Answer: A - Encourage the client to perform circumduction of the feet.
Rationale: Circumduction of the feet involves moving the feet in a circular motion, which helps promote blood circulation and prevent stasis in the lower extremities. This movement aids in preventing venous thromboembolism by reducing the risk of blood clots forming in the legs postoperatively. Encouraging this activity is crucial in maintaining vascular health and preventing complications.
Summary of Incorrect
Choices:
B: Keeping the client's knees in a flexed position while in bed may lead to decreased circulation and increase the risk of venous stasis.
C: Massaging the client's legs every 4 hours can dislodge blood clots and increase the risk of embolism.
D: Limiting fluid intake can lead to dehydration, which can increase the risk of clot formation due to thicker blood consistency.